ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Dana N LeVine; Robert Goggs; Barbara Kohn; Andrew J Mackin; Linda Kidd; Oliver A Garden; Marjory B Brooks; Erin R B Eldermire; Anthony Abrams-Ogg; Elizabeth H Appleman; Todd M Archer; Domenico Bianco; Shauna L Blois; Benjamin M Brainard; Mary Beth Callan; Claire L Fellman; Jillian M Haines; Anne S Hale; Alice A Huang; John M Lucy; Shana K O'Marra; Elizabeth A Rozanski; John M Thomason; Jenny E Walton; Helen E Wilson

doi:10.1111/jvim.17079

ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

J Vet Intern Med. 2024 Jul-Aug;38(4):1982-2007. doi: 10.1111/jvim.17079. Epub 2024 May 23.

Authors

Dana N LeVine¹, Robert Goggs², Barbara Kohn³, Andrew J Mackin⁴, Linda Kidd⁵, Oliver A Garden⁶, Marjory B Brooks⁷, Erin R B Eldermire⁸, Anthony Abrams-Ogg⁹, Elizabeth H Appleman¹⁰, Todd M Archer¹¹, Domenico Bianco¹², Shauna L Blois⁹, Benjamin M Brainard¹³, Mary Beth Callan¹⁴, Claire L Fellman¹⁵, Jillian M Haines¹⁶, Anne S Hale¹⁷, Alice A Huang¹⁸, John M Lucy¹⁹, Shana K O'Marra²⁰, Elizabeth A Rozanski¹⁵, John M Thomason⁴, Jenny E Walton²¹, Helen E Wilson²²

Affiliations

¹ Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA.
² Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
³ Small Animal Clinic, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany.
⁴ Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA.
⁵ Linda Kidd Veterinary Internal Medicine Consulting, Carlsbad, California, USA.
⁶ School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA.
⁷ Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁸ Flower-Sprecher Veterinary Library, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁹ Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.
¹⁰ Department of Internal Medicine, The Animal Medical Center, New York, New York, USA.
¹¹ Bluff City Veterinary Specialists, Memphis, Tennessee, USA.
¹² College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, USA.
¹³ Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA.
¹⁴ Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁵ Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA.
¹⁶ Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA.
¹⁷ Zia Pet Hospital, Rio Rancho, New Mexico, USA.
¹⁸ BluePearl Pet Hospital, Kirkland, Washington, USA.
¹⁹ Oradell Animal Hospital, Paramus, New Jersey, USA.
²⁰ Northwest Veterinary Critical Care Services, Vancouver, Washington, USA.
²¹ Veterinary Apheresis Service UK, Washington, Tyne and Wear, United Kingdom.
²² Langford Vets, University of Bristol, Langford, Somerset, United Kingdom.

Abstract

Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.

Keywords: glucocorticoids; immunoglobulin; immunosuppressive; platelet; transfusion; vincristine.

MeSH terms

Animals
Cat Diseases* / drug therapy
Cat Diseases* / therapy
Cats
Consensus
Dog Diseases* / drug therapy
Dog Diseases* / therapy
Dogs
Immunosuppressive Agents / therapeutic use
Purpura, Thrombocytopenic, Idiopathic* / drug therapy
Purpura, Thrombocytopenic, Idiopathic* / therapy
Purpura, Thrombocytopenic, Idiopathic* / veterinary

Substances

Immunosuppressive Agents